Edward White, MD
In 2002, my wife Daria and I traveled to St. Lucia in the West Indies to volunteer. Orthopedics Overseas, part of Health Volunteers Overseas, had a clinical opportunity and the island had the reputation of being a good place for novice volunteers to get their feet wet.
I did orthopaedics and Daria, whose background is child counseling, went into some schools to do what she does best: sprinkle fairy dust on children’s spirits. St. Jude’s Hospital, where I served, had 25 years of accumulated donated surgical equipment, very little of which was complete. The fracture table was broken, the power equipment was a Black and Decker drill in a plastic bag, the most common plates and screws were sparse, a full selection of intramedullary (IM) rods had no instrumentation, a poor selection of IM rods had full instrumentation; the operating room had no C-arm or portable films. Well, you get the picture.
I awoke the first morning a little anxious about what the 3-week experience had in store for me. I felt up to the task, because my years as a general orthopaedist on the coast of Maine had given me some good “alone time” with my decisions, but facing the “unknown” gave my adrenals a squeeze.
A memorable “breaking in”
It wasn’t long before someone told me that a hip fracture patient had been admitted during the previous night. I thought, “Well, the fracture table is broken and I have no intraoperative imaging, but at least I’m familiar with my foe.” I went to the ward to check the radiograph and the patient.
When I arrived, I grabbed the edge of the film and held it up to the light with that “now, let’s see what we have here” gesture that we used before we had a picture archiving and communications system. What I saw made my heart skip a beat: a comminuted fracture/dislocation of the acetabulum.
The femoral head was in the patient’s buttock, the acetabular roof was up, the back wall was out, and lots of little pieces were scattered around. In my practice, I’d rarely seen these injuries; I had a good relationship with the trauma orthopaedists at the level 1 trauma center in Portland, just an hour away, and would normally send this type of injury to them. But this was my first case as a humanitarian volunteer; someone had to be joking!
I bought time by reading up on the treatment options, but discovered the advice (“Don’t try this at home—or without a CT scanner and intraoperative fluoroscopy.”) wasn’t very helpful. I had no scanner, intraoperative imaging, or trauma center where I could send my 34-year-old patient, “Gibson”, a public transport van driver. My only choice was to move forward.
Before long, I was scrubbed and gowned, making the incision that I’ll remember the rest of my life. I performed a trochanteric osteotomy (increased the trauma by making a controlled break in the thigh bone for better exposure) and set about piecing the acetabular fragments together with two intersecting 100-degree tubular plates and multiple 3.5 mm cortical lag screws. Needless to say, I was very careful with the screw lengths, flying blind toward iliac vessels and the bladder. It took me a few hours but, thankfully, no mishaps occurred.
The next day I saw a postoperative radiographic image of the pelvis. It was like getting the results of an important exam. Incredibly, it looked pretty good! The acetabulum was anatomically restored.
I walked around like a peacock until afternoon rounds brought me down a notch. We had unsuccessfully attempted to get a cube of windshield glass off of Gibson’s right eardrum, and I had told him he’d have to wait 4 days until the ear-nose-throat doctor arrived. But during the rounds, Gibson told me he’d gotten the glass out on his own—by tilting his head and banging the other side with his hand. I suddenly didn’t feel so clever.
Four years later, I saw Gibson again. At that time, he was doing all activities, including playing soccer. In 2011, 9 years postinjury, I took another radiograph of his hip even though he had no complaints and, as it turns out, no arthritis! I started to feel proud again.
Celebrating an anniversary
Many visitors to St. Lucia are familiar with its iconic Pitons, two volcanic plugs that are the result of cooling lava. The 2,500-foot spires sit side by side on the water’s edge on the southwest coast.
It is a significant feat to climb the slightly taller Gros Piton, unless one is a technical climber (then, it’s just a walk in the park). The 4- to 5-hour round trip on Gros Piton, made more fun by the tropical heat and the 45-degree pitch, is an attraction for school field trips and tourists seeking adventure and a way to exercise off the rum punch and indulgences from the day before.
When I saw Gibson’s 2011 radiograph and learned he had never climbed Gros Piton, I told him that in 2012, to celebrate the 10th anniversary of his accident, we’d climb the mountain together. And, we did just that. On Dec. 10, 2012, Gibson and I arrived at the summit of Gros Piton, tired, sweaty, thirsty, and content. It was the proudest moment of my career.
Edward White, MD, is an HVO volunteer who practices at Lincoln Medical Partners in Damariscotta, Maine.